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1

Introduction

Changing population age structures are compelling governments to create or revamp policies and programs that affect many facets of life. In Japan, the parliament voted in early 2000 to cut public pension benefits and raise the retirement age, mirroring the private pension reductions announced by the country's largest employers. Throughout Europe, persistent levels of below-replacement fertility have led to projected (and in some countries current) declines in total population size, prompting nations once opposed to large-scale immigration to rethink such policies in light of likely future shortages of workers and growing numbers of pensioners. In parts of sub-Saharan Africa, grandparents have become the principal caregivers for large numbers of children who have lost their parents to the HIV/AIDS epidemic. In the United States, the Congressional Budget Office projects that the proportion of gross domestic product (GDP) now devoted to social security, Medicare, and Medicaid will more than double (to 17 percent) by the year 2040, with most of the change occurring in the health arena.

The global population is aging at an accelerated rate. While the size of the world's elderly population has been growing for centuries, what is new in the 21st century is the rapid pace of aging and the graying of populations at very different levels of socioeconomic development. Long-term trends toward lowered fertility and improved health and longevity have generated growing proportions and numbers of older population throughout most of the world. Fertility decline and urbanization arguably were the dominant global demographic trends during the second



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Page 15 1 Introduction Changing population age structures are compelling governments to create or revamp policies and programs that affect many facets of life. In Japan, the parliament voted in early 2000 to cut public pension benefits and raise the retirement age, mirroring the private pension reductions announced by the country's largest employers. Throughout Europe, persistent levels of below-replacement fertility have led to projected (and in some countries current) declines in total population size, prompting nations once opposed to large-scale immigration to rethink such policies in light of likely future shortages of workers and growing numbers of pensioners. In parts of sub-Saharan Africa, grandparents have become the principal caregivers for large numbers of children who have lost their parents to the HIV/AIDS epidemic. In the United States, the Congressional Budget Office projects that the proportion of gross domestic product (GDP) now devoted to social security, Medicare, and Medicaid will more than double (to 17 percent) by the year 2040, with most of the change occurring in the health arena. The global population is aging at an accelerated rate. While the size of the world's elderly population has been growing for centuries, what is new in the 21st century is the rapid pace of aging and the graying of populations at very different levels of socioeconomic development. Long-term trends toward lowered fertility and improved health and longevity have generated growing proportions and numbers of older population throughout most of the world. Fertility decline and urbanization arguably were the dominant global demographic trends during the second

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Page 16half of the 20th century, much as rapid improvements in life expectancy characterized many nations during the first half of the century. Today, population aging is poised to emerge as a preeminent worldwide demographic phenomenon. From a historical perspective, population aging represents a human success story. As education and income levels and access to safe, effective contraception have risen, increasing numbers of individuals have been able to achieve their lower reproductive goals. Moreover, most people live much longer lives, in better health, and with different personal expectations than their forebears. For example, people now expect to live for many years after leaving full-time work. At the same time, the sustained shift in population age structure poses an array of challenges to policy makers. Questions such as the following are rising to the top of many political agendas: How do changes in the ratio of workers to retirees affect the ability of societies to fund old-age security systems? Are we living healthier as well as longer lives, or are our added years accompanied by disabilities and poor health status? In what ways can the structure and the delivery mechanisms of health systems best adapt to the needs of older populations that have a higher prevalence of chronic disease? How do changes in family structure affect the demand for public transfers of money, time, and space? Will shifting age distributions result in increased or decreased national saving and investment? Social scientists have already spent a good deal of time trying to find answers to such questions. The purpose of this report is to inform policy makers about the current state of knowledge, as well as to identify the types of data that, if collected, could assist in policy decisions necessitated by the transition to a more-aged society. Research conducted during the last decade suggests that efforts to answer questions such as those posed above can benefit substantially from a multidisciplinary approach. Recent empirical work on the importance of cross-domain relationships—between health and retirement decisions, between economic status and health, between family structure and well-being in older age—supports the contention that public policy should be guided by an understanding of the interplay of multiple factors. Policies to address changing worker/retiree ratios, for example, must be informed not only by demographic considerations, but also by examination of incentive structures for retirement, the changing health profile of older workers, and an understanding of household decision making with regard to work and retirement patterns. Planning for an aging society thus requires innovative research programs that can yield data on interrelated domains of life, a theme to which we return below and throughout this report. Moreover, policies and programs need to be informed by both macro and micro perspectives

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Page 17on aging. At the macro level, we need a clearer picture of the impact of existing policies and programs on decisions with regard to workforce transitions, health care utilization, and a variety of intergenerational transfers. At the micro level, we need to understand the various dimensions of well-being (e.g., physical and emotional health, economic status, family and interpersonal relationships), patterns of age-related transition along these dimensions, and their interrelationships. We can anticipate with some degree of certainty the demographic parameters and trends that give rise to broad policy issues. More elusive is the extent to which individual transitions within various statuses are policy responsive. Ultimately, policy options must be grounded in an understanding of individual and family behaviors and their responsiveness to changing circumstances. IS THERE A “CRISIS OF AGING”? In the year 2000, the net balance of the world's elderly population increased more than 750,000 each month. Two decades hence, the net increase likely will be on the order of 2 million per month (U.S. Bureau of the Census, 2000). The magnitude of the increase in the absolute number of the world's elderly has led to popular perceptions that population aging may overwhelm or radically alter important social institutions. Warnings have been sounded about the likely collapse of public pension systems; about rampant health care costs that may result in age-based rationing of care; about intergenerational conflict as the economics of old age siphon resources away from education, day care, and youth training programs; and about the ability of society's most basic institution, the family, to continue caring for its older members. There is, however, ample reason to believe that nations will be able to cope with current and projected demographic changes provided policy makers have access to information about the emerging economic and social forces that will shape future societal well-being. Indeed, an overarching theme of this report is that both aging and policy responses to the phenomenon are highly malleable. Not long ago, the stereotypical view of individual aging was one of overall decline and certain inevitable outcomes: cessation of work, increasing disability, deteriorating social networks, and often a descent into poverty. We now know, however, that no single formula describes old age and that older individuals are as heterogeneous as younger ones along many dimensions. Yet there may be a structural lag in attitudes, policies, and practices regarding older persons (Riley et al., 1999). One policy challenge is to recast aging populations as a natural resource rather than a societal drain, and to exploit opportunities to use these growing reservoirs of human capital.

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Page 18 This report rejects both an alarmist and a complacent view of aging, noting that there is time for nations to design and implement the research tools and protocols that will make it possible for future policies to address ongoing structural age change. However, considerable lead time is required to develop the types of data that the scientific community now recognizes as crucial to understanding the aging process. The temporal window of opportunity is shrinking, and nations need to implement clear strategies for generating a stream of continuous information that can guide policy making in this crucial arena in the 21st century. Delayed action could have serious consequences and could indeed result in an “aging crisis” in terms of sharp overall tax increases and reductions in individual health and income benefits during retirement years. THE VALUE AND CHALLENGES OF CROSS-NATIONAL RESEARCH While each country's approach to social policy is a function of unique historical and cultural developments, a primary motivation for undertaking the present study was the belief that nations can learn from each other. In an increasingly interdependent world, the rationale for cross-national research on aging is becoming stronger. A basic function of such research is to allow countries to compare performance. Why, for example, might poverty rates among the elderly differ substantially among neighboring countries? Why do estimates of healthy life expectancy vary widely among countries with similar levels of gross national product (GNP) per capita and well-developed health care systems? What lessons might be transferred from one setting to another? When done well and presented effectively, cross-national comparisons can be powerful motivators for change. The highlighting of differences among nations raises questions about whether national trends are unique and culture-specific or more universal and more fundamental to the human aging process. Comparisons prompt researchers and policy makers to reevaluate existing data, help them identify best practices for similar programs, and facilitate consideration of appropriate interventions. One theme of this report is that countries fall along a continuum in the process of population aging. Despite the historical and cultural differences that may bedevil comparative research, policy makers should be able to learn from the experiences of their colleagues in other countries. In the West, population aging varies among countries, reflecting differing patterns of long-term fertility and mortality decline, as well as the appearance of unexpected demographic changes, such as the post-World War II baby boom in a number of nations. Countries with relatively prolonged baby booms will experience the aging of their populations later, and may

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Page 19be in a position to evaluate the successes and failures of policies adopted in nations with higher proportions of older populations. In some Asian countries, governments provide tax incentives for children to live with or near their parents, and parents can take advantage of children's health insurance. Variants of these programs may be useful elsewhere in the world. Further, the evolution of new political arrangements (such as the European Union) should in theory enhance the desirability of and opportunities for collecting comparable data. Comparative research also enhances understanding of variations in the underlying dynamics of population aging and the effectiveness of similar policies and programs in different national settings. Countries and programs are frequently classified into broad categories that may obscure important variations. For instance, elderly people in Western nations are often portrayed as distanced from their children as compared with less industrialized regions where the elderly tend to live with their children. This simple dichotomy ignores the fact that while levels of elderly-child coresidence are much lower in the West than elsewhere, considerable contact, exchange, and personal care assistance takes place between parents and children. Similarly, variations in the cost of public pension systems and in labor force participation rates across industrialized nations often go unmentioned in sweeping pronouncements about the implications of aging for social security coffers. One penetrating and powerful example of cross-national research suggests that the trend toward early retirement in industrialized nations may have been induced in part by public pension systems themselves (Gruber and Wise, 1999). That is, the benefit structure intended to provide earnings replacement at older ages also offers strong incentives for early retirement, thereby intensifying the financial pressures on the system. This finding implies a causal relationship between policies designed to insure against substantial loss of income at older ages and retirement behavior, highlights the importance of research on system design features that can provide such protection in ways that have the least impact on behavior, and offers a framework within which countries can contrast their experiences and modify policies accordingly. Cost is another consideration that argues for comparative study. Most of the data used in international comparisons today have come from cross-sectional studies of aging populations. Aging is a highly dynamic process, and cross-sectional surveys can capture only a single moment of the dynamic. The bulk of the process must be inferred from sequential cross-sectional surveys or through the creation of hypothetical cohorts to simulate the total experience across the life cycle. Panel studies involving longitudinal data collection are much better suited to capturing the dynamics of individual and group aging. These studies are relatively ex-

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Page 20pensive, and may appear prohibitively so in many nations. At the same time, it can be argued that the cost of a well-designed longitudinal investigation is less than that of a series of cross-sectional studies of equivalent sample size and frequency, while the payoff in terms of benefits to policy making is far greater. In any case, an obvious strategy is for countries to coordinate their research on population aging in order to cross-fertilize the scientific knowledge base and to obtain maximum leverage from relatively modest public investments. Another way to envision the advantages of cross-national research is to consider policy evaluation. One common method of assessing policy interventions is to measure differences between a treatment group (persons targeted by the policy intervention) and a control group (persons unaffected by the intervention). To essentially eliminate bias in estimating policy effects, three conditions are required: (1) there is a sizable comparison group with observable characteristics similar to those of the treatment group; (2) the comparison group is completely unaffected by the intervention; and (3) the treatment and comparison groups are subject to the exact same trends over time. Suppose that researchers and policy makers have only national samples available. Where treatments are universal but only for a specific subpopulation (such as in a medical screening), the first condition fails to be met immediately; that is, no suitable comparison group exists. The second condition fails to be met when there are spillover effects on the rest of the community. Finally, even if a comparison group can be chosen within a community or country, the third condition fails to be met when the two groups are sufficiently different (for example, in terms of health experiences over time). Cross-national comparisons can help on all three counts (see Appendix A for a more formal exposition). Interventions or broader policies often are seen in one country and not another; a prime example is a universal health insurance scheme. Even if the policy is universal within a country, there is international variation, and the before-and-after contrasts can be drawn across countries. Alternatively, different countries may introduce similar interventions or treatments but with different timing, so that the contrast can still be drawn. Second, any spillover effects usually are contained within national boundaries, so that the contrast across countries remains valid. Finally, similar comparison groups can be chosen across countries—for instance, high-income and high-education individuals who are likely to have experienced and to continue to experience similar overall trends. We also note that, even in cases where within-country variation is informative, cross-country comparisons can add substantially to the informative variability of the data and thereby considerably improve the precision with which the impact of interventions is estimated.

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Page 21 While the theoretical benefits of comparative international research for policy making are increasingly clear, the conduct of such research poses a number of challenges. The basic challenges for cross-national research are the development of research questions and designs that can be readily adapted to different social and cultural settings, the harmonization of concepts and measures that provide a reasonably acceptable level of cross-national comparison, and the coordination of data collection and analysis across countries. Each of these challenges represents a major undertaking. Recent decades have seen heightened sensitivity to and substantial technical advances in the validation of measures in different cultural settings, yet many problems remain. Data on the same variable or process may differ in myriad small ways. A prime example is the measurement of activity restriction among older adults using a set of indicators commonly called “activities of daily living” (ADLs). The World Health Organization has recommended the use of a particular ADL instrument. However, a recent analysis of surveys in nine European nations showed that while the use of a set of ADL questions is widespread, there are significant differences among the surveys in both wording and the items included (Robine et al., 2000). These differences preclude comparison of the prevalence of ADL restrictions among countries. In some cases, cross-national measurement problems are trivially easy to correct. For example, temperature measured in Fahrenheit in the United States can be converted to centigrade to conform to the European standard. In other cases, the theoretical idea is well understood but not trivial to implement. Consider the conversion of monetary measures to a common value. Current foreign exchange rates may convert French francs into U.S. dollars, but this conversion may not reflect purchasing power parity, a concept that attempts to equate the true purchasing power of given incomes in France and the United States. For many variables used in studies of health, psychology, and economics, methods for obtaining common measurements are not well understood, in part because they have received inadequate systematic attention from the scientific community. Progress is being made on a number of fronts; for example, there is a continuing large-scale cross-national effort to create instruments that produce valid measures of depression that are comparable across countries, cultures, and language groups. To continue making progress along these lines, active collaboration of scientists from different disciplines and countries is essential. The analysis of data without shared protocols can lead to misleading conclusions. Careful planning of the collection and exchange of comparable data would have long-term benefits that would accumulate over time, benefits that could be shared by countries that may not have the near-term infrastructural capability to implement major country-specific data initiatives.

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Page 22 CHARGE TO THE PANEL Given the crucial implications of burgeoning numbers of older people and the need for a scientific basis for policies addressing the opportunities and problems associated with major shifts in population age structures, the U.S. National Institute on Aging requested that the National Academies convene a panel of experts to explore the scientific opportunities for conducting policy-relevant comparative research on aging. The panel was asked to provide recommendations for an international research agenda and for the kinds of data needed to carry out that agenda in the context of rapid demographic aging. Specifically, the panel was asked to address the following statement of task: To identify the scientific opportunities for conducting policy-relevant cross-national research on aging. To review existing sources of socioeconomic, demographic, and health data on aging populations and to analyze the strengths and weaknesses of current international data collection efforts for addressing the priorities of various countries in aging research. To outline data collection efforts that, if undertaken internationally, would advance understanding of the aging process around the world. To identify potential obstacles to comparative work on aging, such as national variations in common definitions or differences among countries in laws governing privacy and access to data. STUDY APPROACH AND SCOPE The panel's ultimate charge was to produce a set of recommendations regarding issues in research on aging and to identify the data needed to help policy makers better understand the economic and social problems likely to arise with changes in population age structure. The panel's mandate was not to recommend specific policies for dealing with these issues, but rather to identify the types of data and research paradigms that would enable policy makers to make better-informed decisions. In this spirit, the panel: Examined the advantages of multidisciplinary involvement in data development. Highlighted areas in which cross-country analysis is critical. Considered the process by which the scientific community could develop and implement a data-driven research agenda. Examined the advantages that would ensue from combinations of survey and administrative data.

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Page 23 Considered privacy and confidentiality issues relating to the dissemination and use of basic data. The study's core concern was with the behavioral, socioeconomic, and health aspects of human population aging. Therefore, research in the important realms of molecular and cellular aging in various species fell outside the panel's purview. The panel also recognized that related studies on aging by the National Academies and others are currently under way and that it would be largely redundant to focus on topics that are covered thoroughly in existing or forthcoming reports. For example, a considerable amount of work has been done in the field of the biodemography of aging (National Research Council, 1997) and in the emerging area of how to integrate the collection of biological (including genetic) data into population-based surveys (National Research Council, 2001). Likewise, an evaluation of population projection methodology has been completed (National Research Council, 2000a), and current opportunities in cognitive research on the aging human mind have been delineated (National Research Council, 2000b). The United Nations (2000) Population Division recently convened a technical meeting on the living arrangements of older persons. Increasing attention also is being given to macroeconomic effects that may accompany shifting population age structures (see, for example, Peterson, 1999; MacKellar, 2000). While these areas are touched upon at least briefly in this report, relevant discussions may be found in other publications and are not detailed here. The panel debated the important substantive areas in which international comparisons would potentially be most useful, and eventually focused on five interrelated research domains that require new international data to inform policy making in the coming decades: (1) labor force participation and the transition to retirement; (2) patterns and distributions of income, savings, and wealth; (3) changes in family structure and intergenerational transfers; (4) health and disability trends; and (5) subjective assessments of well-being that may be related to, but are largely independent of, conventional financial status and health measures. The panel formed five working groups to address these areas. The relative importance of these domains is likely to differ by society and may change within a society over time. However, if countries want to take advantage of natural experiments currently ongoing throughout the world to improve their own adaptations to population aging, these are the five essential domains that must be addressed by international research. CROSS-CUTTING ISSUES Several cross-cutting issues emerged during the panel's working group and plenary deliberations. Six such issues implicitly underlie the

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Page 24entire report and are discussed explicitly to some degree in each chapter. These issues also played a major role in shaping the panel's recommendations. International applicability. One major obstacle the panel faced was formulating international research recommendations that would be pertinent to countries with diverse patterns of aging and stark differences in research infrastructure. For example, a detailed inventory of stock market holdings, private retirement annuities, fungible wealth, and so on may be crucial to understanding the well-being of older persons in highly industrialized nations, but may be much less important if not irrelevant in predominantly agricultural societies. The terms “developed” and “developing” are still used when grouping countries and making broad generalizations about modernization and economic development, but these categories are increasingly antiquated and may be misleading. While some policy issues regarding aging may be very different in parts of Latin America versus Europe, others may be quite similar. Given the relatively advanced levels of population aging in industrialized nations, this report concentrates primarily, though by no means exclusively, on data issues in these countries. At the same time, the panel believes its recommendations should be viewed in light of a continuum of national research capabilities and needs. In some nations, population aging is just beginning to be acknowledged as a policy concern, and an appropriate first step in research might be simply to mine existing census data and anthropological studies to create a descriptive national profile of the elderly population. In other countries where little research has been conducted on aging per se, there may be valuable troves of existing data (e.g., hospital, clinical, and other administrative records) that could be used in developing an international comparative perspective as a means of stimulating policy debate. And cutting-edge research questions that have relevance in some less industrialized nations may be salient in more industrialized nations as well. As described in Chapter 5, for instance, the complexity of kin networks and the implications for family transfer patterns may be far greater in parts of Africa and Asia than in countries characterized by nuclear family units that have been declining in average size for generations. The interrelated nature of this report's subject matter. As noted earlier, it is essential to recognize that the topics covered in this report are highly interrelated. For example, a large body of research demonstrates a significant relationship between income and wealth on the one hand and health outcomes such as morbidity and mortality on the other (Smith, 1999). Economic status in older age correlates with living arrangements and family transfers of money, time, and space. Health obviously affects the ability to work and the retirement decision, but mounting evidence

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Page 25suggests that the reverse also is true. Ultimately, the quality of life at older ages is affected by all these realms. Understanding and accounting for these functional linkages is crucial to successful policy development. The overriding need for complex data becomes clear given that policy initiatives in one arena may have unexpected and confounding effects in other areas. The value of data linkage. Two potentially conflicting trends in many societies today are the expansion of available data on the one hand and growing concerns about individual protections and confidentiality on the other. The tension between the two is heightened by technological and methodological advances that allow microdata (i.e., at the individual level) from different sources to be linked. Researchers and policy makers find this to be an exciting and extremely useful development, a way to broaden knowledge of aging populations at relatively low cost and without additional survey intrusions (Woodbury et al., 1999). At the same time, they must appreciate the ethical and legal issues that arise. In the United States, the balance between private rights and the public interest in scientific databases constitutes an ongoing debate (see, for example, National Research Council, 1999; National Research Council, 2000c). National policies and laws governing privacy and access to data vary widely and represent significant potential obstacles to comparative research on aging. Finding ways to better exploit and develop data linkages while recognizing the necessity of protecting individual and group rights is a central emphasis of this report. The diversity of the older population. As noted earlier, the term “elderly” conceals the diversity of individuals within an age range that spans more than 40 years. Like younger age groups, persons aged 65 and over have very different personal and social resources, health, living arrangements, and degrees of integration into social life. Underlying this diversity at older ages is the fact that different birth cohorts often have had very different life experiences. Man-made and natural disasters, major health breakthroughs, sudden economic changes, and landmark political decisions may, for example, shape a single 5-year birth cohort in ways that make its members behave in significantly different ways from persons born just before or just after that 5-year period. More gradual processes, such as changes in family structure, improvements in educational attainment, and higher vaccination rates, also cause future cohorts to enter the ranks of the elderly with very different characteristics than those of the current elderly population. One characteristic that elderly populations do not share with younger age groups is their gender balance. Women make up the majority of the elderly population in nearly every country of the world, and their share of the older population increases with age. This numerical imbalance in

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Page 26 favor of women is reflected in many of the topics considered in this report, ranging from disability to marital status to living arrangements. Given that gender differences in such areas as life expectancy, work history, asset accumulation, and care giving pervade most societies, it is imperative that policies regarding the well-being of older individuals account carefully for differential gender impacts. The importance of socioeconomic differences. Related to diversity is the fact that the health of elderly populations in all countries varies according to socioeconomic position. The magnitude of these differences, as well as their causes, varies over time within and among societies. To develop policies effectively, one must have an understanding of these causes, which in turn requires a fuller understanding of the determinants of socioeconomic differences in health and functioning. Policy responses to such differences will ideally cover a wide range of determinants, including the provision of, access to, and response to medical care and social services. Therefore, an underlying need in any research agenda is to include a link to socioeconomic position in the collection of population and health data on elderly individuals. The need to deal with uncertainty. The panel recognizes that aging in the future may be quite different from what we understand it to be today. We can only surmise, for instance, about the impact of new patterns of family dissolution and formation on elders' future support systems and well-being. Will changes in transnational capital flows interact with shifting age structures to produce new patterns of savings and wealth accumulation for old age? Will demographic pressures eventually outweigh ingrained cultural norms and result in political realignments and decisions that substantially affect older persons? Even the underlying process of aging itself may be radically altered by the deciphering of the human genetic code and resultant developments in gene therapy. One major challenge to any research agenda, then, is how to account for such future uncertainty. Can the research designs we propose accommodate, or even anticipate, the unexpected? ORGANIZATION OF THIS REPORT The following chapter reviews the current and projected demographic dimensions of population aging in the global context, with emphasis on the dynamics and worldwide variability of the process. Attention is given to changes in mortality and morbidity and the especially rapid growth of the oldest portions of elderly populations, changes that are likely to have pronounced ramifications for future policy development. Chapters 3 through 7 address in turn the five principal research domains identified earlier; recommendations in each area are provided at

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Page 27the end of the respective chapter. At the same time, given the necessity of studying interrelationships among the five domains as discussed above, an attempt is made in each chapter to cast its main points in the light of linkages to the other domains. Chapter 3 examines patterns of work, retirement, and pension arrangements across countries, as well as pension reforms and their likely impact on retirement behavior. The discussion centers on retirement incentives as key system variables in understanding the transition from work to retirement, and concludes with a delineation of the most important data and methods needed to model retirement behavior and hence inform policy making in this arena. Chapter 4, which deals primarily with issues of savings and wealth, proceeds from a recognition that income security systems, despite their successes in providing generally adequate standards of living in industrialized nations, may have to be substantially revised if those achievements are to be maintained during the next century. One policy that many if not most countries (including those in the developing world) will consider involves some reliance on individual savings and wealth accumulation as a means of supplementing public-tier support. To date, however, we know relatively little about the motivations and propensities for households to save for retirement and about actual wealth levels within and among countries. This chapter highlights the main theoretical issues that arise with regard to household savings and wealth accumulation. It then compares data from six nations with an eye toward salient patterns, quality, and comparability, as well as how our stock of knowledge in this area can be improved. In Chapter 5, the text moves to a discussion of family structure and intergenerational transfers, noting that the well-being of older persons depends to a great extent on the content and volume of an intricate set of transfer systems in which they are engaged throughout their lives. The mix of transfer programs and their salience varies considerably between the more and less developed economies and within each group as well. Many of the key transfer systems can be understood and measured at both the individual and family levels, as well as at the societal or macro level, a fact that presents further challenges to attempts to trace interrelationships across systems. A microbehavioral approach is the major perspective for studying family exchanges, while macroeconomic analysis is the dominant strategy for studying public and employer transfer arrangements. Chapter 6 begins with an overview of the linkages between health and other subjects addressed in this report, and presents a conceptual framework that incorporates many of those linkages. The chapter reviews quantitative approaches to characterization of the health status of

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Page 28older persons, with particular attention to concepts and measurements of functional status. It then turns to the assessment of national heath care systems and their utilization. The quality and availability of extant national and international health data on older persons are considered in light of possibilities for cross-national studies. The chapter concludes with a discussion of the strengths of and obstacles to comparative research on health. The penultimate chapter addresses a common policy goal shared by all countries, the well-being of their elderly constituents. The supreme criterion by which a government can be judged successful is the quality of life its citizens experience from birth to death. Questions of well-being are particularly important during major life transitions, both because such transitions provide a specific frame of reference for the assessment of well-being and because they involve significant changes in activity patterns. Despite a wide range of research efforts over the past half-century, there is little or no consensus on either the conceptual definition or measurement of well-being. Recent research in these areas has proceeded along various lines, and the chapter suggests a need for integration of at least five conceptual levels of well-being: external conditions, subjective well-being, persistent mood level, transient emotional states, and the biochemical/neural basis of behavior. The distinction between stocks and flows is offered as a promising basis for resolving the differences among concepts and measurements. Finally, Chapter 8 puts several of the report's cross-cutting themes into sharper focus. In addition, six overarching recommendations for future research are presented. REFERENCES Gruber, J., and D. Wise, eds. 1999 International Comparison of Social Security Systems . Chicago : University of Chicago Press . MacKellar, F.L. 2000 The predicament of population aging: A review essay. Population and Development Review 26(2): 365-397 . National Research Council 1997 Between Zeus and the Salmon: The Biodemography of Longevity . Committee on Population. K.W. Wachter and C.E. Finch, eds. Commission on Behavioral and Social Sciences and Education. Washington, DC : National Academy Press . 1999 A Question of Balance: Private Rights and the Public Interest in Scientific and Technical Databases . Committee for a Study on Promoting Access to Scientific and Technical Data for the Public Interest, Commission on Physical Sciences, Mathematics, and Applications. Washington, DC : National Academy Press .

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Page 29 2000a The Aging Mind: Opportunities in Cognitive Research . Committee on Future Directions for Cognitive Research on Aging. P.C. Stern and L.L. Carstensen, eds. Commission on Behavioral and Social Sciences and Education. Washington, DC : National Academy Press . 2000b Beyond Six Billion: Forecasting the World's Population . Committee on Population. J. Bongaarts and R.A. Bulatao, eds. Commission on Behavioral and Social Sciences and Education. Washington, DC : National Academy Press . 2000c Improving Access to and Confidentiality of Research Data: Report of a Workshop . Committee on National Statistics. C. Mackie and N. Bradburn, eds. Commission on Behavioral and Social Sciences and Education. Washington, DC : National Academy Press . 2001 Cells and Surveys: Should Biological Measures Be Included in Social Science Research? Committee on Population. C.E. Finch, J.W. Vaupel, and K. Kinsella, eds. Commission on Behavioral and Social Sciences and Education. Washington, DC : National Academy Press . Peterson, P.G. 1999 Gray dawn: The global aging crisis. Foreign Affairs 78(1): 42-55 . Riley, M.W., J. Riley, and A. Foner 1999 The aging and society paradigm. In Handbook of Theories of Aging: In Honor of Jim Birren , V.L. Bengston and K.W. Schaie, eds. New York : Springer . Robine, J-M., C. Jagger, and V. Egidi 2000 Selection of a Coherent Set of Health Indicators . Montpellier, France : Equipe INSERM Demographie et Sante . Smith, J.P. 1999 Healthy bodies and thick wallets: The dual relationship between health and economic status. Journal of Economic Perspectives 13: 145-166 . United Nations 2000 United Nations Technical Meeting on Population Aging and Living Arrangements of Older Americans. Available: http://www.undp.org/popin/popdiv/untech/untech.htm [February 27, 2001]. U.S. Bureau of the Census 2000 International Data Base. Available: http://www.census.gov/ipc/www/idbnew.html [February 28, 2001]. Woodbury, R., A. Gustman, L. Lillard, O. Mitchell, and R. Willis 1999 The Value of Linked Data in Aging Research. Paper prepared for April 17-18, 2000 meeting of the Panel on a Research Agenda and New Data for an Aging World, Washington, DC .